Washington worst in nation for emergency health care

January 5, 2009

By Jon Savelle

When it comes to Washington residents’ access to emergency health care, the state gets a flunking grade.

The American College of Emergency Physicians delivered this unflattering assessment in its recently released “National Report Card on the State of Emergency Medicine,” which looks at such criteria as access to care, quality of care, safety, medical liability, public health and injury prevention, and disaster preparedness.

Each category was graded, and it was the access question for which Washington earned an F. The state also nearly flunked, with a grade of D-, in the category of “medical liability environment.” On the other hand, Washington did very well in quality of care and public health, with a grade of A in each.

“We have a lot to be proud of in Washington in terms of this report and obviously a long way to go in some areas to support our emergency patients,” said Eric Shipley, an Overlake Hospital physician and the president of the Washington chapter of the emergency physicians’ group. “We have the systems and programs in place to take wonderful care of our patients, yet we’re in desperate need of more primary care physicians and mental health providers, as well as more emergency departments overall.”

According to the physicians’ group, Washington’s low grade for medical liability reflects two things: its lack of a liability cap on non-economic damages in malpractice suits, and its lack of a requirement that expert witnesses be of the same specialty as the defendant.

With its F for access to emergency care, Washington ranks dead last in the nation, the Report Card states. The reasons for the failure are complex and there is no plan that would fix it.

John Milne, Swedish Medical Center’s medical director for strategic development and a physician at the center’s Issaquah emergency room, said the access problem is closely linked to the availability of hospital beds in the region.

“We have the lowest number of intensive-care-unit beds in the nation per capita,” he said. “The problem is surge capacity. When the ambulance drops you off, that’s only the first stage in the process. You need a hospital bed to go to. There are times, in King County, when there is not an ICU bed to go to.”

On any given day, Milne explained, the region’s hospitals are running at 98 percent of capacity. That means an emergency patient, once stabilized in the emergency room, may have to wait days for a hospital bed. This burdens emergency departments and leaves no room in the system should a disaster cause mass casualties.

Donna Smith, medical director for Virginia Mason Hospital in Seattle, agreed. She said her organization has done a lot of work to reduce delays, but surge periods are still a problem.

“We can do a better job coordinating the use of emergency departments in the area,” Smith said. “People have really realized, in the past couple of years, that the emergency department is the front door. But access really depends on flow [of patients] through the hospital.”

Virginia Mason operates an ambulatory clinic in Issaquah.

At the Swedish emergency room in Issaquah, patients are sent wherever they will receive the care most appropriate to their condition, Milne said. About 40 percent go to Overlake Hospital in Bellevue, some go to Evergreen Hospital Medical Center in Kirkland, and some go to Swedish Hospital in Seattle.

“From a regional standpoint, we have a real challenge having enough capacity,” Milne said. “That’s what they are referring to when they talk about access.”

Building more emergency rooms would help somewhat, but it does not solve the shortage of hospital beds. And if more hospitals are built — as both Swedish and Overlake want to do in Issaquah — it provides the beds but does not solve a shortage of skilled nurses.

“You might have a physical bed, but without a nurse, it is pretty much meaningless,” Milne said.

The nursing shortage is felt nationwide, but it is more acute in Washington because of the way nurses are trained here, according to Milne. Whereas nurses used to be trained on the job in hospitals, in recent decades that role has shifted to the state’s community colleges.

But those programs are understaffed and underfunded. Instructors are scarce, despite heavy demand for training.

“The salary for a professor in a community college nursing program is less than what they can make as a nurse on a hospital floor,” Milne said. “There is almost a disincentive for a good nurse to go teach.”

Barring any sudden improvement in that situation, the nursing shortage will get worse. Milne said many nurses are in their 50s and nearing retirement age, which will exacerbate the shortage of staffed hospital beds and access to emergency care.

“From a regional standpoint, we have a real challenge having enough capacity. That’s what they are referring to when they talk about access.”